percutànea de etanol en lesiones tiroideas
J Clin Ultrasound 2002
guided percutaneous ethanol treatment of a symptomatic complex nodule with
a large cystic component in a patient with thyroid hemiagenesis.
M, Basaria S, Mesa C Jr, Stolf AR, Graf H.
de Endocrinologia e Metabologia do Hospital de Clinicas da Universidade
Federal do Parana, Rua Padre Camargo, 262, Curitiba 80.060, Brazil.
hemiagenesis is a rare anomaly that is usually discovered incidentally
during the evaluation of unrelated thyroid disorders. We present the case
of a patient with hemiagenesis of the left thyroid lobe and a large,
recurrent, symptomatic complex nodule with a large cystic component that
occupied most of the right lobe. She had previously undergone multiple
unsuccessful aspirations of the cyst. The patient was successfully treated
with an intranodular injection of ethanol under sonographic guidance. The
success of this procedure resulted in the resolution of symptoms and
avoidance of surgical resection of the right lobe, with resulting
hypothyroidism. We recommend that ethanol injections be considered for
treatment of symptomatic cystic or benign solid nodules in patients with
thyroid hemiagenesis and in those who have undergone hemithyroidectomy and
have symptomatic nodules.
Pathol Int 2002
study of papillary thyroid carcinoma treated with percutaneous ethanol
H, Shimizu K, Kitagawa W, Naito Z, Kawanami O, Tanaka S.
of Surgery, Nippon Medical School, Tokyo and Department of Pathology,
Nippon Medical School, Tokyo and Department of Molecular Pathology, Nippon
Medical School, Kawasaki, Japan.
86-year-old male patient was treated by percutaneous ethanol injection
therapy (PEIT), following tumorectomy of a papillary thyroid carcinoma and
a modified radical neck dissection for its metastasis. After seven
treatments with PEIT, the patient was admitted to hospital for a
tracheotomy to treat progressive severe dyspnea. Seven days later the
patient died from acute renal failure caused by diabetic ketoacidosis. At
autopsy, tumor masses were found to comprise mostly scar tissue, and the
remaining neoplastic cells often showed anaplastic changes. Fresh
coagulation necrosis and hemorrhages were scattered throughout the tumor
lesions and their microvessels were occasionally occluded by thrombus.
These changes were seen prominently, especially at the central areas of
PEIT treatment. Given these findings, we believe that PEIT may be useful
in providing local control for the progression of thyroid cancer,
especially in cases of unresectable malignant thyroid tumors.
APMIS 2002 Feb;110(2):172-6
changes in thyroid nodules after percutaneous ethanol injection in
patients subsequently operated on due to new focal thyroid lesions.
L, Bartos M.
of Endocrinological and General Surgery, Institute of Endocrinology,
Medical University of Lodz, Poland.
paper reports macro- and microscopic changes in hyperfunctioning thyroid
nodules (HTN), initially diagnosed as solitary, in patients treated with
percutaneous ethanol injection (PEI). In 78 patients, benign solitary HTN
were diagnosed by clinical and hormonal examination. High resolution
ultrasonography confirmed the solitary nodule. The results of fine needle
aspiration biopsy (FNAB), performed twice, ruled out malignancy of the
nodule. The patients were referred for PEI treatment. At 1-year follow-up,
newly formed thyroid nodules, whose volumes increased, were detected in
five patients (6.4%) with HTN, initially diagnosed as solitary. Therefore,
these patients were operated on. Subtotal thyroidectomy was performed. At
the intraoperative macroscopic evaluation, a hard fibrous solid mass was
found in place of three nodules (n1, n2, n3) following PEI treatment. The
middle area of the cut surface of PEI-treated nodules (n4 and n5) in the
other two patients was firm and haemorrhagic, surrounded by a fibrous mass.
Histolopathologic examination of n1, n2 and n3 revealed fibrosis and
hyalinosis. Examination of n4 and n5 showed haemorrhagic necrosis in the
middle of the nodules surrounded by fibrous tissue.
Clin Radiol 2001
ethanol injection of autonomous thyroid nodules with a volume larger than
40 ml: three years of follow-up.
Prete S, Russo D, Caraglia M, Giuberti G, Marra M, Vitale G, Lupoli G,
Abbruzzese A, Capasso E.
Operativa di Oncologia, Ospedale S. Giovanni di Dio, Frattamaggiore, Italy.
Autonomous thyroid nodules are conventionally treated by surgery or
radioiodine. Percutaneous ethanol injection is a recognized alternative
approach. An assessment of the long-term success and safety was conducted.
MATERIALS AND METHODS: Thirty-four patients (seven men and 27 women; age
range: 32-80 years; mean: 56 +/- 13 years) with an autonomous thyroid
nodule (ATN) > 40 ml (volume range 41-180 ml; mean: 63.6 +/- 34.5 ml)
were treated with ultrasound-guided percutaneous ethanol injection (PEI).
All patients were hyperthyroid with increased radionuclide uptake in the
nodule at scintigraphy. Serial serum (free T3, free T4 and thyroid-stimulating
hormone (TSH)) and ultrasound studies were performed at 3, 6, 12, 18, 24
and 36 months after the first PEI session. Scintigraphy was performed
before treatment and 1 month after the serum TSH became detectable or
alternatively after 6 months, even if the TSH was still undetectable.
RESULTS: Each patient had 1-11 sessions of PEI, with an injection of 3-14
ml of ethanol per session (total amount of ethanol per patient: 20-125
ml). Within 3 months from the end of the treatment, the recovery of
extranodular uptake on isotope scan and the normalization of TSH levels
were observed in 30/34 patients. A reduction (average: 62.9%) of nodule
volume was recorded in all patients and only 4/34 patients were refractory
to PEI. The responsiveness of ATN to PEI appeared to be dependent on the
initial nodule volume (3/4 failures in patients had nodule volumes > 60
ml). Side-effects were always self-limiting. During follow-up (6-36 months)
no recurrence was observed. CONCLUSION: In conclusion, the treatment of
ATN > 40 ml with PEI would appear to be a valid alternative approach to
traditional methods of treatment. It is safe, well tolerated and
inexpensive. Its acceptability when compared with surgery and radiodioine
has still to be assessed.
Acta Radiol 2001
of autonomous and toxic thyroid adenomas by percutaneous ultrasound-guided
B, Sucic M, Bozikov V, Hauser M, Hebrang A.
of Radiology, University Hospital Merkur, Zagreb, Croatia.
To evaluate the feasibility and efficacy of US-guided percutaneous ethanol
injection (PEI) in the treatment of autonomous and toxic thyroid adenomas.
MATERIAL AND METHODS: PEI was performed in 42 patients with solitary,
scintigraphically "hot" nodules (n=37) or toxic nodular goiter
(n=5). The nodular volume ranged from 2.5 to 38 cm3 (mean volume,
20.7+/-14.1 cm3). Ethanol was injected using a free-hand technique,
usually in multiple sessions, using color and power Doppler US guidance.
Treatment success was evaluated following 3-4 months after PEI by
scintigraphy, hormonal status, and US findings. RESULTS: The procedure was
technically successful in 39 patients (93%). Three patients were lost to
follow-up. Minor complications were pain (all patients), subcutaneous
hematoma (n=6), and transitory dysphonia (n=1). A complete cure was
achieved in 22 patients (52%), and a partial cure in 10 patients (24%). In
4 cases (9%), the result was unsatisfactory since only moderate hormonal
remission was observed. A satisfactory results was thus achieved in 32/42
patients (76%). Significant nodular volume reduction was observed in all
cases. Better results were observed in smaller nodules and in cases of
autonomous adenomas. There were no cases of recurrent hyperthyreosis.
CONCLUSION: US-guided PEI is an efficient and safe method in the treatment
of autonomous thyroid nodules and it enables inactivation of nodules with
minimal or transitory complications.
Thyroid 2000 Dec;10(12):1087-92
and pathological changes after percutaneous ethanol injection therapy of
F, Caraccio N, Basolo F, Lacconi P, LiVolsi V, Miccoli P.
of Internal Medicine, University of Pisa, Italy. email@example.com
data exist on the operative and pathological findings in patients having
undergone previous percutaneous ethanol injection (PEI) therapy of thyroid
nodules. We report here our experience with 13 patients operated on by the
same surgical team. Two pathologists, both blinded to the previous PEI
treatment, carried out histological evaluation. Reasons for surgery
included PEI failure, suspicion of malignancy, and tracheal compression.
The operations did not pose any special problem from the technical point
of view, and the postoperative courses were uneventful. One patient who
had a second operation developed hypoparathyroidism, and laryngeal nerve
palsy was never observed. The histological diagnosis was hyperplastic or
adenomatous nodule in 12 cases and papillary thyroid cancer in 1. No
difficulty was found in evaluating the nodule capsule and surrounding
vessels. In two lesions, nuclear enlargement and clearing were identified
in thyroid follicles immediately adjacent to necrotic or scarred areas.
These changes were considered reactive. In conclusion, patients previously
treated by PEI were operated on without special technical problems.
Histological diagnosis was not hindered, and there was no difficulty in
ruling out malignant lesions. PEI, however, should be performed only by
skilled operators, and incidental ethanol seepage throughout the nodule
capsule must be carefully avoided.
Thyroid 2000 Nov;10(11):985-9
and percutaneous ethanol injection in the treatment of large toxic thyroid
nodule: a long-term study.
M, Torlontano M, Ghiggi MR, Frusciante V, Varraso A, Liuzzi A, Trischitta
ed Unita di Ricerca di Endocrinologia, Istituto di Ricovero e Cura a
Carattere Scientifico, San Giovanni Rotondo, Fg, Italy. firstname.lastname@example.org
is generally recommended for large thyroid toxic nodules (TTNs). When
surgery is not applicable, both radioactive iodine (RAI) and percutaneous
ethanol injection (PEI) are alternative treatments. In this retrospective
study, the long-term efficacy of nonsurgical treatments was evaluated in
43 patients with TTN, selected on the basis of presence of hyperthyroidism
and a fairly large nodule (3- and 4-cm in diameter) completely inhibiting
controlateral lobe captation during scintigraphy. Twenty-one patients were
treated by RAI (administered dose 670+/-160 MBq; range 555-925) and twenty-two
were treated by PEI (6+/-1 sessions; range 5-9). FT4, FT3, thyrotropin (TSH),
and nodule volume were assessed before and at fixed intervals after
treatment. Median follow-up was 36 months (range, 12-84). Compared to
baseline values, with both therapies, serum FT4, FT3, and nodule volume
were decreased (p < 0.01) and serum TSH was increased (p < 0.01),
after 3 months and during the entire follow-up. Nodule volume reduction
percentage was 66.8+/-22.0 and 78.4+/-18.0, in the RAI- and PEI-treated
groups, respectively. At the end of follow-up, 34 patients were euthyroid
(16 RAI- and 18 PEI-treated). Four RAI-treated patients (19%) showed
slightly high TSH levels (4.2-5.3 mU/L), whereas three PEI-treated
patients (13.6%) still had suppressed TSH levels, although being
clinically asymptomatic. One RAI-treated patient (4.8%) showed overt
hypothyroidism during the follow-up period and was then treated with L-thyroxin.
One patient (4.6%), who was initially cured by PEI, became newly
hyperthyroid during the follow-up period. Both treatments were well-tolerated.
In conclusion, both of these nonsurgical treatments are effective and may
be chosen also for relatively large TTNs. Specifically, RAI seems to be
more effective for treating hyperthyroidism but has minimal sequelae of
subclinical or clinical hypothyroidism, while, after PEI treatment the
possibility of stable subclinical hyperthyroidism or hyperthyroidism
relapse should be taken into account.
Radiology 2000 Jan;214(1):143-8
ethanol injection of large autonomous hyperfunctioning thyroid nodules.
L, Giorgio A, Mariniello N, de Stefano G, Perrotta A, Aloisio V, Tamasi S,
Forestieri MC, Esposito F, Esposito F, Finizia L, Voza A.
Service, D. Cotugno Hospital, Torre del Greco (Na), Italy.
To verify the effectiveness of percutaneous ethanol injection (PEI) in the
treatment of large (>30-mL) hyperfunctioning thyroid nodules. MATERIALS
AND METHODS: Twelve patients (eight women, four men; age range, 26-76
years) with a large hyperfunctioning thyroid nodule (volume range, 33-90
mL; mean, 46.08 mL) underwent PEI treatment under ultrasonographic (US)
guidance. US was used to calculate the volume of the nodules and to assess
the diffusion of the ethanol in the lesions during the procedure. When
incomplete necrosis of the nodule was depicted at scintigraphy performed 3
months after treatment, additional PEI sessions were performed. RESULTS:
Four to 11 PEI sessions (mean, seven) were performed in each patient, with
an injection of 3-14 mL of 99.8% ethanol per session (total amount of
ethanol per patient, 30-108 mL; mean, 48.5 mL). At scintigraphy after
treatment in all patients, recovery of extranodular uptake, absence of
uptake in the nodule, and normalization of thyroid-stimulating hormone (thyrotropin)
levels were observed. In all patients, US showed volume reductions of
30%-50% after 3 months and 40%-80% after 6-9 months. Side effects were
self-limiting in all patients. During the 6-48-month follow-up, no
recurrence was observed. CONCLUSION: PEI is an effective and safe
technique for the treatment of large hyperfunctioning thyroid nodules.
Thyroid 1999 Aug;9(8):763-7
ethanol injection may be a definitive treatment for symptomatic thyroid
cystic nodules not treatable by surgery: five-year follow-up study.
M, Torlontano M, Chiarella R, Ghiggi MR, Nirchio V, Bisceglia M,
and Research Unit of Endocrinology, Scientific Institute Casa Sollievo
della Sofferenza, San Giovanni Rotondo, Italy. email@example.com
present a prospective study on the long-term efficacy of percutaneous
ethanol injection (PEI) treatment for thyroid cystic nodules. Among
patients referred for symptomatic thyroid cystic nodules who had relapsed
after two aspirations or whose nodules could not be aspirated due to the
thickness of the cystic fluid, PEI was given when surgery was either
refused or contraindicated. Forty-three patients were treated; the mean
basal volume of the cysts was 38.4 mL. The purpose of the study was to
evaluate long-term efficacy of PEI treatment on: (1) amelioration of
symptoms and signs of local compression and (2) nodule volume reduction.
In three subjects (7%), PEI failed to induce a significant (>50%)
nodule reduction, so that surgical treatment was performed. In 40 patients
(93%), an impressive nodule shrinkage was observed, reaching a plateau
after 24 months (volume reduction = 91.9%+/-11.4%). A new PEI session was
needed in two patients in whom a recurrence was noted within the first 6
months. After 6 months, no significant (> or =1 mL volume) nodule
regrowth was observed up to 60 months. Both symptoms and tracheal
displacement rapidly (within 1 month) and significantly (p<0.01)
improved. After PEI, mild pain was the only side effect observed. No
suspicious cytology was observed in any residual nodule greater than 1 mL
6 and 24 months after the last PEI session. Our data suggest that PEI is a
first-line safe, effective, probably definitive, treatment for cystic
thyroid nodules for which surgery is either refused or contraindicated.
Thyroid 1999 Mar;9(3):225-33
ethanol injection therapy in benign solitary solid cold thyroid nodules: a
randomized trial comparing one injection with three injections.
FN, Hegedus L.
of Endocrinology, Odense University Hospital, Denmark. firstname.lastname@example.org
aim of the present study was to evaluate the efficacy of percutaneous
ethanol injection therapy (PEIT) with special reference to dose response
and symptom score and to describe side effects in a parallel-group
randomized clinical trial with 6 months of follow-up, comparing 2
different treatment strategies. Sixty euthyroid outpatients with a benign
solid and scintigraphically solitary cold thyroid nodule causing local
discomfort were assigned to 1 session with a single intranodular injection
of sterile 98% ethanol (PEIT-1, n = 30) or 3 weekly sessions with 1
injection of sterile 98% ethanol (PEIT-3, n = 30). In the PEIT-1 group,
the pretreatment nodule volume was 9.9+/-5.7 mL (mean +/- SD). It
decreased to 7.0+/-4.7 mL after 1 month, and 5.6+/-5.9 mL after 6 months
(p = 3.2x10(-6)), and the ethanol dose given was 24.7%+/-7.5% of the
pretreatment nodule volume. The overall reduction in nodule volume was
46%. In the PEIT-3 group the pretreatment nodule volume was 9.4+/-4.2 mL.
It decreased to 5.9+/-3.5 mL 1 month after the last session, and 4.6+/-2.6
mL after 6 months (p = 4.0x10(-10)), and the cumulative ethanol dose given
was 47.9%+/-21.3% of the pretreatment nodule volume. The overall reduction
in nodule volume was 51%, and the difference between the 2 treatment
regimens was 5.3%+/-5.5% (mean +/- SE of difference, p = 0.3). A
satisfactory treatment dose, defined as a total intranodular spread of
ethanol visualized on the monitor screen, was achieved in only 50%-60% of
the sessions. This was due to pain that necessitated premature
discontinuation of the injection and was apparently severe enough in 3
patients in the PEIT-3 group that they refused additional treatment.
Twenty-two of 30 (73%) patients in the PEIT-1 group and 19 of 30 (63%) in
the PEIT-3 group had a marked effect on symptoms at 6-month follow-up (p =
0.6). Side effects comprised transient thyrotoxicosis in 2 patients,
permanent ipsilateral facial dysesthesia and increased flow of tears in 1
patient, paranodular fibrosis impeding subsequent surgery in 1 case and
various degrees of pain and tenderness related to PEIT in nearly all.
Major side effects were dose dependent. We conclude that PEIT is effective
in inducing necrosis and reducing the volume of benign solid cold thyroid
nodules. The additive effect of 2 additional doses compared with 1 dose is
insignificant. The optimum management strategy has yet to be clarified.
Limitations relate to the procedure being quite painful despite local
anesthesia and the fact that side effects are in no way negligible, and
therefore, a word of caution in routine use is advisable. Publication
N Engl J Med 1998 May
of benign nodular thyroid disease.
AR, Huysmans DA.
of Endocrinology, University Hospital Nijmegen, The Netherlands.
J Clin Endocrinol Metab 1998
of percutaneous ethanol injection therapy versus suppressive doses of L-thyroxine
on benign solitary solid cold thyroid nodules: a randomized trial.
FN, Nielsen LK, Hegedus L.
of Endocrinology, Odense University Hospital, Odense C, Denmark.
results of studies using suppressive doses of L-T4 on benign solitary
solid cold thyroid nodules have been conflicting. Recently, intranodular
injection of absolute ethanol has been proposed as an effective treatment,
but has been evaluated only in uncontrolled studies. Our objective was to
evaluate the effect of two alternative medical treatment modalities,
percutaneous ethanol injection therapy and L-T4, on the benign solitary
solid cold thyroid nodule. In a prospective randomized clinical trial, 50
euthyroid patients with a single solid colloid thyroid nodule causing
local discomfort were assigned to a single intranodular injection of
sterile 98% ethanol (n = 25) or suppressive doses of L-T4 (n = 25). We
aimed at an ethanol dose of 20-50% of the pretreatment nodular volume. The
initial daily dose of L-T4 was 1.5 microg/kg BW and was adjusted monthly
during the first 6 months to reduce serum TSH to subnormal levels
(<0.40 mU/L). Thyroid nodule volume and total thyroid volume were
assessed by ultrasound, and thyroid function was determined by routine
assays before and during follow-up. Symptom scores before and at 12 months
were evaluated by a questionnaire rating pressure symptoms and cosmetic
symptoms. The median ethanol dose given was 21% [95% confidence interval
(CI), 18;25] of the pretreatment nodule volume. In this group, the median
reduction in nodule volume was 47% (CI, 33;57; P < 0.0001) compared to
9% (CI, -7;22; P = 0.09) in the L-T4 group. The difference between the two
treatment regimens was statistically significant (P < 0.0001). The
median reduction in perinodular thyroid volume was 20% (CI, 11;31; P =
0.03) in the L-T4 group, whereas no change was seen in the ethanol group
(-2.5%; CI, -18;11; P = 0.9). Fourteen of 25 (56%) patients treated with
ethanol injection and 8 of 25 (32%) treated with L-T4 had complete relief
of symptoms at 12 months of follow-up (P = 0.09). No major side-effects
were seen in either group. Percutaneous ethanol injection therapy
administered as a single small dose results in a satisfactory clinical
response in approximately 50% of patients by halving the nodule volume.
The thyroid nodule-reducing effect of L-T4 suppressive therapy is
insignificant, but a subjective satisfactory clinical response is seen in
a subgroup of patients, probably explained by the concomitant reduction of
perinodular thyroid volume.
Thyroid 1997 Oct;7(5):699-704
percutaneous ethanol injection a useful alternative for the treatment of
the cold benign thyroid nodule? Five years' experience.
N, Goletti O, Lippolis PV, Casolaro A, Cavina E, Miccoli P, Monzani F.
of Internal Medicine, University of Pisa, Italy.
describe our 5-year experience with percutaneous ethanol injection (PEI)
for the treatment of cold benign thyroid nodules and report its efficacy
and side effects. Fifty-four euthyroid outpatients (aged 44.8+/-12.7 years,
mean+/-SD) were divided into two groups matched for sex, age, and nodule
volume: 27 patients treated only by PEI and 27 patients treated
additionally with levothyroxine-suppressive therapy (median follow-up: 24
months, range 6-48). Mean pretreatment nodule volume was 21.0 mL (range
5.4-54.6). Ethanol (1.3+/-0.6 mL/mL nodule volume) was injected under
sonographic control in 4 to 13 weekly sessions (mean 7.4). PEI therapy was
well tolerated by all patients. At the end of treatment, nodule volume was
7.7+/-5.7 mL (p = .0001). A further significant shrinkage was obtained at
1-year follow-up (4.4+/-3.8 mL; p < .05). No significant differences in
nodule reduction were observed between the levothyroxine treated or
untreated group and between patients with pretreatment nodule volume
smaller or larger than 15 mL. Our study confirms the efficacy and safety
of PEI in inducing volume shrinkage of cold benign thyroid nodules.
Overall our data suggest that PEI may become an interesting alternative
for patients with surgical indications, if they refuse surgery or are poor
surgical risks, or eventually demand treatment for aesthetic purposes. It
may also be considered when levothyroxine therapy is contraindicated or